Online Health Chat with Bruce Long, MD, and Lynn Pattimakiel, MD
May 10, 2016
An estimated 57 million Americans are affected by osteoporosis and low bone mass. Osteoporosis is often called the silent bone thief, and it can be both debilitating and painful. However, there are things you can do now that may help prevent osteoporosis from occurring, or progressing. Proper medical care can help you slow or even reverse its progress and prevent fractures.
Osteoporosis results in an increased loss of bone mass and strength. The disease often develops without any symptoms or pain, and it is usually not discovered until the weakened bones cause painful fractures. Most of these are fractures of the hip, wrist and spine.
Our experts discuss how both men and women are affected by this metabolic bone disease. They address topics such as how it develops, early detection and prevention strategies that focus on balance and falls, nutrition, and the variety of osteoporosis medications available.
About the Speakers
Bruce Long, MD, is a staff physician in the Department of Rheumatic and Immunologic Diseases. He is active in the Center for Osteoporosis and Metabolic Bone Disease. Prior to Dr. Long’s appointment at Cleveland Clinic, he was chair of the Department of Rheumatology at Fairview and Lutheran hospitals. He is board certified in rheumatology and internal medicine, and his specialty interests include osteoporosis and bone disorders, Vitamin D, autoimmune disorders and pharmacology. Prior to entering the profession of medicine, Dr. Long practiced pharmacology in his home state of Illinois.
Lynn Pattimakiel, MD, is a staff physician in the Department of Internal Medicine at Cleveland Clinic. She practices in the Center for Specialized Women’s Health. Dr. Pattimakiel’s clinical interests are in women's health, osteoporosis, menstrual disorders, menopause and CustomFit Physicals for women. She earned her medical degree at Medical University of Debrecen and completed her residency in internal medicine at St. Vincent Charity Hospital. Her fellowship was in women’s health at Cleveland Clinic’s Center for Specialized Women’s Health.
Let’s Chat About Osteoporosis
BSD: How important is it to be taking calcium supplement when taking Prolia. I was advised to take 1500 mg, but I cannot tolerate it. I am presently taking 500 mg (with magnesium and 2000 units of D3) with a daily stool softener. I am OK but unable to increase comfortably. My diet is good (vegan) and I exercise daily, but my bone density test keeps getting worse. I’m hoping Prolia will do the trick.
Lynn_Pattimakiel,_MD: Constipation is a common side effect patients experience with calcium intake. We do recommend getting 1500 mg of calcium a day in divided doses, because this is optimum for bone health. The best way to get this calcium is through your diet. If you can aim for four to five servings of calcium a day with calcium rich foods, you may not need to take a calcium supplement on top of this. If you do not get an adequate amount in your diet, you can make the difference up with a calcium supplement. We really encourage diet first. If you do experience constipation, magnesium is very helpful as well as MiraLAX.
bbofranpd: How much Vitamin D and what kind should someone 85 with osteoporosis take a day?
Bruce_Long,_MD: We base the amount of Vitamin D prescribed on your blood level. As we get older, we are less efficient in making Vitamin D in our skin. On average, most adults in Cleveland need about 2000 units of Vitamin D3 daily.
jannasnanny: Should I take calcium supplements? I have been reading so much about calcium supplements and increased heart attack risk. How do I know if I should be on a bone drug? What physical activities are safe with osteopenia?
Lynn_Pattimakiel,_MD: We promote getting calcium in your diet as the healthiest way to take calcium, if possible. Your goal is getting at least 1500 mg/day in divided doses. There have been reports of getting too much calcium, which could lead to kidney stones, or calcium being deposited in the arteries. It is important to be screened for osteoporosis with a bone mineral density test at least at the age of 65, or earlier if you have significant risk factors. This will guide if you need to be on a bone medication. Other risks, which could indicate need for medication, include certain medications that can cause bone loss or if you have a stress fracture (which may indicate weaker bones). Many physical activities are safe with osteopenia. We do recommend small weight-bearing exercises such as walking with three to five pound weights, yoga (with simple poses) and balance exercises. If you have severe bone thinning/weakness, I would recommend being evaluated by a physical therapist to help guide safe exercises and give your restrictions on how much weight you can safely lift.
softballmom: I am 55 and was told last year after having a bone test that I have osteoporosis. I am now taking Alive Calcium with Vitamin D3. Is this what I should be taking to try to stop it from getting worse? Is there something to fix the damage that is already done?
Lynn_Pattimakiel,_MD: Calcium and Vitamin D3 are great supplements that all women need as building blocks to help with bone formation. If you were diagnosed with osteoporosis, Calcium and Vitamin D3 are not enough for therapy. There are a variety of medications that are used in therapy that either help slow the breakdown of the bones, so your body can naturally rebuild, or that actively build bone. Their use is based on the severity of your disease. You also have many options of how to take these medications including orally, as intramuscular injections or IV. These medications have been shown to not only stabilize bone loss, but improve bone density as well.
kurlanger: Is jogging OK if you have osteopenia?
Bruce_Long,_MD: Osteopenia implies that your bone strength is low, but not too low. Jogging should be fine, just don't slip.
Farrell: What do you mean by "walking with three to five pound weights"? Carrying one in each hand? Wearing weight bands on the ankles? I was told several years ago that walking with weights sets you off balance and was not good for back muscles.
Lynn_Pattimakiel,_MD: Ankle weights are not routinely recommended, especially if there is concern for balance issues. I would recommend walking with small hand weights if there is no contraindication such as arthritis. Push-ups against the wall are another great exercise.
ommom: I am post-menopausal and was diagnosed with osteopenia of the hip and have a -2.5 on L2. I walk on a treadmill, which may be helpful for my hips. What kind of exercises can I do specifically for my spine? I also take a yoga class.
Lynn_Pattimakiel,_MD: With the T score of -2.5, you carry the diagnosis of osteoporosis. Walking and yoga are excellent for your bone strength, although make sure you are not doing any crazy poses in the yoga class that may be dangerous to your spine. Push-ups against the wall are often recommended. I would also recommend an evaluation with physical therapy to help guide you specifically on different exercises that are safe to complete.
Bertha: Does slow motion, high intensity strength training provide much benefit?
Bruce_Long,_MD: Are you thinking of tai chi? It is beneficial in muscle strengthening and balance, and people find it fun.
BarbaraAdelle: I am 83 and recently diagnosed with osteopenia. I exercise regularly but do not take calcium because of constipation problems. I was also diagnosed with some backbone deterioration. Do certain exercises cause osteopenia to be worse?
Bruce_Long,_MD: Except for space walking (astronauts lose bone in space), I can't think of an exercise that would cause osteopenia to be worse. Weight-bearing exercises provide important stress on bone so bones become stronger. Some calcium products are more constipating and others. Have you tried calcium citrate?
PAD: I have a family history of osteoporosis (paternal aunt, mother) and osteopenia (brother and father). In my early 30s I was diagnosed with osteopenia. I'm also post-menopausal. I'm now 45, take calcium and vitamin D, and exercise (mostly walking), but I could do better in this category. My questions are: What are my chances of getting osteoporosis? What can I do to decrease my chances? My PCP says I'm too young for medications (which is fine with me). What would be my next step?
Lynn_Pattimakiel,_MD: It sounds like you are doing all the right things and are staying on top of your health. You do carry some higher risk factors, which include first degree relatives with osteoporosis and an early age of onset of menopause. Within the first five to seven years of menopause, we often see the most significant decline in bone mass. Make sure you are aiming for a total of 1500 mg of calcium per day in divided doses, and Vitamin D3 2000 IU daily OTC. Exercise is great, but to help promote bone strength, we recommend adding some weight-bearing exercises, including walking with small weights or yoga. The other important step is to get continued bone mineral density tests at least every two years to make sure that your strength of bone remains stable.
Scuffy: Can the progression of osteoporosis be stopped with diet and/or supplements alone?
Bruce_Long,_MD: Generally not. Most of us will also need a medication in addition to calcium, vitamin D and exercise.
Alaina: If your recent bone density scan shows that you have osteoporosis, how much bone are you able to gain back and what specific measures are the best to accomplish that?
Bruce_Long,_MD: The question is excellent but very complicated. The amount of bone improvement varies with the cause of osteoporosis, other underlying illnesses, extent of exercise, absorption of calcium, adequacy of Vitamin D, individual genetic factors and, especially, the bone medicine used. Studies have shown that bone can become 20 percent stronger or more with therapy.
Nottingham: I had been diagnosed with osteoporosis late last year with a lumbar spine T-score of -2.5 (left femoral -1.7 and left total hip -1.8). The recommendation right away was a bisphosphonate. I researched and have not been convinced that it is the best treatment based on the half-life of the drugs, the margin of error with the scan and speaking with my dentist. In the interim, I have been walking more on the treadmill vs. the elliptical, taking calcium 500 mg with D400 mg twice a day and adding more calcium-rich foods to my diet. One supplement recommendation received is from Standard Process: Calcifood Powder, Ostrophin PMG, Cataplex D and Cal-Ma Plus. What is your treatment recommendation? If I were to begin a treatment option, how would my bones be monitored? Is the bone turnover marker an earlier option than waiting two years for another scan? Or, is there another available monitoring method? Thank you.
Bruce_Long,_MD: Treatment of osteoporosis always involves five parts: Adequate calcium, adequate Vitamin D, weight-bearing exercises, something to bring better balance between cells that remove bone (osteoclasts) and cells that build bone (osteoblasts), and eliminating bad stuff (smoking, too much alcohol, etc.). You may be taking too much calcium based on what you seem to be taking. Total consumption post menopause is 1200 to 1500 mg daily, which includes food and supplements. I don't think you need the other supplements. Bisphosphonates as a group are among the safer drugs we have in modern medicine and are the most popular, but not for everybody. The jaw problems you may have read about are rare events. I like that you are considering bone turnover markers. I think that will help guide you and your doctor to decide on therapy and can give you a clue on how your bone in doing instead of waiting for another DXA.
Pehartman: What is a bone turnover marker?
Bruce_Long,_MD: Bone turnover is the term for the relationship of cells that make bone (osteoblasts) and cells that remove bone (osteoclasts). The activity of these cells can be assessed by lab tests such as urine or blood NTX or CTX, osteocalcin, alkaline phosphatase, procollagen type 1. Those tests are called "bone turnover markers".
Farrell: What is your opinion on use of cross-link N-telopeptide to monitor bone deterioration between bone density tests?
Bruce_Long,_MD: We routinely use that test to monitor bone changes and the effect of therapy. I think it is a very important test.
bcgbrandt: I received a zolendronic acid shot last August. Is there a way to evaluate if it is working before I get another one? I had a bone density test in fall 2014/winter 2015, so I am not eligible for another one so soon.
Lynn_Pattimakiel,_MD: Bone density tests are recommended every two years to monitor the strength of your bones. If you had a urine NTX (bone resorption) marker before starting therapy, we could recheck this in three to six months and see if it remains low after therapy. This result may be variable though from lab to lab, and may not give accurate results, so we usually do not rely on this as a sole indicator.
kurlanger: Who should have bone turnover marker and cross-link N-telopeptide testing?
Lynn_Pattimakiel,_MD: Bone turnover markers (in the urine and blood) have been used to monitor the response of therapy. The use of these markers is not routinely recommended because the results may not always be accurate from lab to lab.
NOM54: An osteoporosis specialist has suggested that I consider switching from a weekly oral medication to a twice yearly injection. It's easy to stop a weekly medication due to side effects, etc., but an injection is a six-month commitment. I subsequently realized I would like to improve my comfort level in that regard to the switch. Can you speak to that concern? Additionally, the cost is prohibitive since I am on a high deductible health plan. Can you speak to the cost issue?
Lynn_Pattimakiel,_MD: The best question to ask is why the specialist is recommending switching. If you are tolerating and remembering to take the oral, once-weekly medication without significant side effect or risk, and if your bone density tests seem to be stable or improved, I would recommend staying with this medication. If for some reason you are unable to use this medication or you are not getting a good response due to absorption issues, then the twice yearly injection may be a good option for you. It carries some of the same risk factors as the oral medication that you are taking, but is generally well tolerated. The specialist does need to monitor your calcium levels when taking this medication, and it is not recommended for anyone who has a low immunity status. Insurance coverage varies, and this is why proper documentation would be beneficial to state why the oral medication is not effective.
catherine472: Bisphosphonates are generally recommended for those with osteoporosis, yet there seems to be controversy as to whether or not they are appropriate for patients who have not yet had a fracture. The numbers needed to treat are high, bone mineral density (BMD) is shown to increase but benefits in actually preventing fractures have not been proven. They have been associated with osteonecrosis of the jaw even with oral use, and esophageal/GI complications. We know the drug companies have pushed these drugs when they may not really be beneficial and now they have become a "standard." What is your feeling on this controversy?
Lynn_Pattimakiel,_MD: There is evidence of bisphosphonate use and the reduction of fracture in both the hip and spine. Again, it is not recommended for everyone for prevention but especially for patients who are identified as higher risk. We often use the FRAX model to help guide this decision. There will always be benefits and side effects/complications associated with all medication, and this is why it is important that we use them appropriately. The risk for osteonecrosis of the jaw is low, compared to the morbidity and mortality associated with hip fracture in patients with osteoporosis, but, again, we need to weigh the risk and benefit for each individual patient.
LJK123: I am a female age 81. I took Fosamax for eight years for my osteoporosis. Eventually, the bone test showed I had osteopenia and I was taken off the drug. This was many years ago. I have herniated discs and arthritis in my back that gives me continuous pain. Should I be taking some drug for osteoporosis at this time?
Lynn_Pattimakiel,_MD: It sounds like you were on a good treatment of your bones, and the bone density test improved. It is important to continue to monitor the strength of your bones with a bone density test at least every two years. If there is a sign of significant worsening, restarting the medication may be an option. Unfortunately, it will not help with the herniated discs and the arthritis pain. It is used to help improve the strength of your bones and prevent future spine fractures.
loribradshaw: Please explain the contradiction between hormone replacement therapy (HRT) for osteoporosis and reducing HRT as one ages. I was told by one doctor I should not take so much HRT and another to take more to protect my bones. Thanks.Lynn_Pattimakiel,_MD: In women taking postmenopausal hormone therapy, the benefit is reduction of bone loss, especially in women with osteopenia. It is not considered therapy for women with the diagnosis of osteoporosis. Hormone therapy has many benefits but does carry side effects with them as well, including blood clots and stroke. As women get older, their individual risk factors need to be re-evaluated to make sure that it continues to be safe to take the hormone therapy. There is no time limit to how long you should stay on hormone therapy, but, again, it should be reassessed on a regular basis. After the age of 60, women may be able to get the same benefit of the medication at a lower dose, but symptoms and bone density tests still need to be monitored.
cosmona: Do you have any thoughts on what should be the next course of action for someone who has taken Forteo for two years? Fosamax or HRT? Thank you.
Lynn_Pattimakiel,_MD: It is often recommended to follow the two-year course of Forteo with bisphosphonate therapy, preferably with the once yearly IV formulation if no contraindication, for best improvement of your bone density.
catherine472: I was on Actonel for about seven years and have not had any for the last eight years. It upsets me that I was prescribed it for osteopenia when it wasn't really indicated. Should I be concerned now about starting it again? My endocrinologist does not advise it even though I have some osteoporosis.
Lynn_Pattimakiel,_MD: Bisphosphonate therapy often works longer in your bones because of its longer half-life. It may be indicated in patients with osteopenia who are calculated to have a higher risk of fracture. It is important to continue to monitor your bone density tests regularly. If there is worsening of your bone density test or if you suffer from a stress fracture, this would be an indication to be evaluated for starting therapy for your bones.
Making Sense of Medication
bones: I have a bone density of -5. How much improvement is possible in the two years of treatment with Forteo? Why the two-year treatment limit? Is it because of increased concerns of side effects? I am told clinical studies found bone cancer in rats, but no increase in two years of treatment in humans. Is this info correct? Also, in the NY Times 12/21/15, "12 Minutes of Yoga for Bone Health" by L. Fishman, a study suggests it may actually improve bone mass. Do you have any comments? Beyond yoga, do you have any suggestions on other ways to improve posture and prevent spinal fractures?
Bruce_Long,_MD: Your bone density is very low. There are multiple factors involved in the rate of bone improvement (age, smoking, diet, exercise, other underlying conditions), so it is hard for me to give you a good answer on how much you might improve. The two-year use is based on the fact that when Forteo was studied, the study was two years. It was stopped early because a particular breed of rats, (Fischer 344 rats), which are genetically engineered to get bone cancer, got bone cancer, and some of the scientists thought they got it sooner than expected. No other animal or human developed bone cancer in the study. Weight bearing exercises are important in developing bone. Muscle strength is also important. Yoga is a great form of exercise. Other exercises can help posture and balance, too, and a physical therapist can help you.
Katie D: Are there any concerns regarding long-term use of Fosamax?
Bruce_Long,_MD: Although Fosamax is among the safer medicines we have, after long-term use, there have been rare reports of osteonecrosis of the jaw and atypical femoral shaft fractures. We found that some people can take a "drug holiday" from Fosamax. As with all drugs, you and your doctor have to weigh the benefits versus the risks of taking a medicine.
mataki: I have systemic sclerosis and want to stay away from bisphosphonates, even the injectable ones. My doctor has recommended raloxifene, which I agreed to, especially because many relatives in my family have had breast cancer. Can you comment on how raloxifene works and how much protection it provides for the bones? I have heard that it might not be reflected in a bone density test. Thank you.
Lynn_Pattimakiel,_MD: Raloxifene has been shown to be a good medication in reducing risk for spine fractures and would be a great option, especially if there is concern for a high risk for breast cancer in the family. We would still be able to monitor your bone density test to monitor the response and strength of your bones. I would not recommend taking oral bisphosphonates due to esophageal risks, but the once yearly IV option still may be a good option for you if they are able to obtain IV access.
daveluft: Can you speak to the drug Forteo. Apparently, it is a daily injection for two years. I am led to believe it is the only medicine that may build bone rather than just stabilizing bone loss. My oral surgeon was very much against Prolia, which is my present medication, if undergoing a bone graft and implant procedure.
Bruce_Long,_MD: You are correct. At this time Forteo is the only available bone-building medicine (anabolic agent). Prolia might interfere with the bone building needed in the jaw area after bone graft and implant. I would think Forteo would help bone growth.
NOM54: Dr. Long, I see that you are a staff physician in the Department of Rheumatic and Immunologic Diseases. Are there rheumatic and immunologic factors that are causative or associated with the development/treatment of osteoporosis? I have had Hashimoto's disease for 25 years, am now experiencing arthritis and have the osteoporosis severity of someone in my 80s although I am in my early 60s. I have been treated with Fosamax for about three years and am considering switching to Prolia. I am getting appropriate levels of calcium and D3 and exercising more, but I’m making very small gains.
Bruce_Long,_MD: Lupus, rheumatoid arthritis and ankylosing spondylitis are some of the rheumatic diseases associated with osteoporosis risk. Excessive thyroid hormone can cause bone loss, but I wouldn't worry, as I believe your doctor is monitoring your thyroid level.
Pehartman: I am a 55-year-old male who has osteoporosis, and I also suffer from kidney stones. Could the two conditions be related? In addition, I also have very low testosterone. Could that also be a factor?
Bruce_Long,_MD: There are many causes of kidney stones. An overactive parathyroid gland (hyperparathyroidism) can be associated with kidney stones and osteoporosis. Low testosterone is among the more common causes of osteoporosis in men.
bbofranpd: I have osteoporosis and also lost a kidney from kidney stones and can't take calcium. What can I do?
Bruce_Long,_MD: I suggest you discuss this with your kidney specialist. It may be possible for you to take calcium citrate. You also may be able to get more calcium from your diet.
That is all the time we have for questions today. Thank you, Dr. Long and Dr. Pattimakiel, for taking time to educate us about osteoporosis.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.
To make an appointment with Bruce Long, MD, or any of the other specialists in our Department of Rheumatologic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/rheum.
To make an appointment with Lynn Pattimakiel, MD, or any of the other specialists in the Center for Specialized Women’s Health, please call 216.444.4437, or call toll-free at 800.223.2273, ext. 44437. You can also visit us online at clevelandclinic.org/womenshealth.
For More Information
The Center for Osteoporosis and Metabolic Bone Diseases at Cleveland Clinic is a national leader in osteoporosis research and in other forms of disease that affect bone. Early evaluation for risk of the disease, identification and treatment of osteoporosis can help prevent clinical manifestations of what is considered a silent disease.
The Center sees patients with osteoporosis and other metabolic bone diseases including Paget's disease, osteomalacia, osteogenesis imperfecta and others. The center has a state-of-the-art bone densitometer to assess bone density in the hip and spine, as well as radius and total body when clinically indicated. This technique allows the physicians to evaluate the degree of bone loss and to diagnose osteoporosis and the risk for future fracture. Pain management and physical therapy may be integrated into a treatment plan if osteoporosis is advanced or fracture has occurred. Cleveland Clinic’s Department for Rheumatologic and Immunologic Diseases is ranked No. 2 in the nation by U.S . News & World Report and top ranked in Ohio.
The Center for Specialized Women's Health specializes in interdisciplinary mid-life women’s health. Women can access specialized health care at the Center for Specialized Women's Health as well as referral to other areas of the Clinic if needed. In addition to routine wellness exams and health care screenings by our nurse practitioner, we offer CustomFit Physicals for women, menopause consults and evaluation and treatment of numerous medical problems of special concern to women including osteoporosis, hormone disorders, urinary leakage, sexual dysfunction, menstrual disorders, vulvar problems and weight concerns. Center professionals are happy to accommodate patients who are seeking second opinions, as well as patients who prefer female providers.
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